PLANNING AND DEVELOPMENT ACCESSING ASSISTED LIVING TECHNOLOGY Social Work Principles and Good Practice Guidance: Use of Assisted Living Technology PAGE 1
Content 1. Introduction 3 2. Considering Using Assisted Living Technology 3 3. Practical/Technical Issues Around Assessment 4 4. Ethical Considerations 5 Questions which assessors must ask before using Assisted Living Technology 5. Informed Consent Consent Withheld When people are unable to provide informed consent 6 Appendix 1 Technology Advisors and their role as part of an infrastructure that supports appropriate access to Assistive Technology 8 Appendix 2 Procedure: For Accessing Assisted Living Technology Assessors Checklist 9 Appendix 3 Assessment and Appropriate Equipment 11 Appendix 4 Assessing the Reason for Falls Equipment to better manage falls 13 2
PRINCIPLES AND GOOD PRACTICE GUIDANCE: USE OF ASSISTED LIVING TECHNOLOGY 1. INTRODUCTION 1.1 This document and its appendices set out the principles which underpin the Department s policy and guidance on the use of Assisted Living Technology, describes the range of equipment available, gives advice about its use and a checklist for assessors to consider before using the new technology described. 1.2 The term Assisted Living Technology is used in North Lanarkshire Council, for the application of advanced electronic equipment, which can be used as part of the arrangements to monitor people s welfare, enhance their support and care and compensate for disability. It can act as a prompt for intervention by carers or paid staff and /or assist in assessment of need and care planning. 1.3 Assisted Living Technology can be used to enhance the alert service, which is provided through Merrystone Care Base at Coatbridge, or, on a stand-alone basis. It can automatically alert (with no action by the service user) a carer or Merrystone Care Base of an event, or incident. 1.4 While recent advances in technology have led to the development of a range of devices that may reduce the levels of risk and further enhance quality of life. Care has to be taken however to ensure that the use of any device is strictly controlled and does not impinge on individual human rights. The use of this new technology must therefore be consistent with this guidance on policy and procedures. It will be subject to regular review by a senior officer. 2. CONSIDERING USING ASSISTED LIVING TECHNOLOGY 2.1 A community alarm may need to be in place before any Assisted Living Technology can be installed. Some older alarm units may only take a few pieces of equipment and may need replaced. The Technology Advisors within area teams will inform you of what is required (see app 1). 2.2 There are a number of issues, which need to be considered, before supplying Assisted Living Technology, as part of a care plan. These are - the need for a person centred approach, risk assessment, consideration of other potential solutions to a specific problem, the relative cost (financial and person centred) of alternatives solutions and questions about dignity and privacy. 2.3 The use of Assisted Living Technology can raise particular issues, which have attached risks. These risks are practical, technical, ethical and financial in nature. 3
3. PRACTICAL/TECHNICAL ISSUES AROUND ASSESSMENT 3.1 With regard to technical and practical matters assessors must be clear about both the potential and limitations, which technology and its application has, to reduce dangerous situations, faced by vulnerable individuals. 3.2 A balance needs to be found between the wish to ensure privacy and safety and for a realistic view of potential risks for service users to be judged. For example, carers, health and social care staff and neighbours often report that someone with dementia has gone outside at night. Equipment can be used, so that e.g. a front door of a house, being opened between 12.00 midnight and 8.00a.m. (Pre-set times), activates an automatic message to Merrystone Care Base. This may elicit a resultant response from a mobile unit. 3.3 While the risk posed by going out at night might be correct, it does not always mean that concerns expressed by third parties are accurate. Sometimes, those expressing concern can overestimate risk. It is important therefore that assessors/care managers clarify what risk, actually exists, before considering installing Assisted Living Technology. The true risk may not justify its use but alternatively, if deployed properly, it may provide appropriate monitoring and reassurance for the service user and carer. If wrongly used however, it may provide false reassurance and be a waste of resources. 3.4 Since the application of Assisted Living Technology has limitations, therefore assessors must be clear what they, service users and carers understand and expect from the equipment and this should be reflected in care plans. (This is not unique however to the use of technology and applies to many social care services). e.g. An assessor may conclude that the risk of someone with dementia going out, in the early morning is real. The assessor could arrange for the installation of a piece of equipment to indicate, if someone has opened a front door of a house in the early hours of the morning and gone out. Such an action could notify Merrystone Care Base that the person may be in danger outside and consequently prompt a check visit. 3.5 When there is a doubt about, the frequency or occurrence of risky behaviours (such as the above) the technology can also provide information about the individuals propensity for such behaviour and inform care planning. 3.6 Installation of another piece of equipment could, indicate that unlit gas was turned on in someone s kitchen. Receipt of this information, could result in a check visit being made. 3.7 In both examples above, although an automatic notification would be generated and could alert someone to visit, the technology would be limited in that it could not prevent the person going outside or unlit gas being turned on. In the latter example response time would be crucial, otherwise the responder may also be at risk, in this instance a gas isolation tap may be the only alternative at the present time. 4
4. ETHICAL CONSIDERATIONS 4.1 As Assisted Living Technology has the potential to be very intrusive, in people s lives, assessors and care managers must also ensure that individual dignity and privacy are respected and not abused, by its use. The Human Rights Act 1998 places requirements on the Department regarding these issues. Wherever practicable assessors should consult and respect service users wishes. If someone is able to make a rational informed decision not to have intrusive technology, this needs to be respected. The consequences, however, also need to be explained to them, in an open honest fashion. 4.2 In cases where people are not able to make rational informed decisions, other safeguards need to be in place (See below). 4.3 For these reasons, a consent procedure and appropriate advice must be part of the decision making process for installing and using Assisted Living Technology. Part of this process is the need for approval of installing Assisted Living Technology equipment by Community Care Seniors, regular initial monitoring after installation and regular review. 4.4 QUESTIONS WHICH ASSESSORS MUST ASK BEFORE USING ASSISTED LIVING TECHNOLOGY Who will benefit from the use of the Assisted Living Technology? E.g. the person, their carer, the service provider. Has a full assessment been completed and risks identified? Is the technology being considered to fill a skill gap? Is safety more important than privacy? What is the risk? How likely is it to happen? What would technology do to reduce the actual risk? What are the limitations of the technology? Is technology the best option to reduce the risk to a reasonable level? Is it really needed? 5
5. INFORMED CONSENT Consent is fully informed and achieved by good verbal communication between the individual and the person responsible for assessing their needs and arranging their care. The practitioner should record in the individual s notes that consent has been agreed. 5.1 CONSENT WITHELD In some cases consent may be withheld. Where the assessor is quite clear that the person understands the possibilities and the limitations of using Assisted Living Technology and refuses to consent to its use. The practitioner should advise of the consequences e.g. the person may be at serious risk if they remain at home without supervision/monitoring and due to budgetary priorities, the possibility of over night care by paid staff, may not be an alternative. Assessors/care managers should also record the person s decision not to use technology. The issue should only be reconsidered again if circumstances change or the person changes their mind. 5.2 WHEN PEOPLE ARE UNABLE TO PROVIDE INFORMED CONSENT There will be many reasons why an individual may not be able to provide consent. If this happens the assessor should consider the following. Is there a legitimate need to use Assisted Living Technology due to the level of risk? Is this the least restrictive intervention possible at this time? Are the wishes of the adult being considered in the broader sense e.g. has the person previously expressed a wish to stay at home but cannot do so safely without this equipment. Best practise should be a consensus between the person, carers and professionals. This should then be recorded. Assessment should always take on board the views of other relevant interested parties, e.g. Carer, Home Support Worker, GP etc. In some instances it may be necessary to involve an advocate to act on a service user s behalf, particularly if there is a conflict of interests. If it seems appropriate to proceed, the decision should be recorded why and who was involved and confirmed by the community care senior. The assessor/care manager should then discuss how best to meet the person s needs, with the team Assisted Living Technology adviser. 6
N.B. Whenever possible the consent of the person should be sought. Where possible, the element of control should be with the person. All decisions made on behalf of the adult with impaired capacity must: Benefit the adult Take account of the adult s wishes, if these can be ascertained. Take accounts of the views of relevant others, as far as it is reasonable and practicable to do so. Restrict the adult s freedom as little as possible while still achieving the desired benefit Encourage the adult to use existing skills or develop new skills. The process of consent or making decisions on behalf of an adult should be formally reviewed at least annually. Where the consent status changes the appropriate people should be informed and records updated accordingly. The timetable for reviews will be dependent on the individual needs of the person using the equipment and will be influenced by the nature of the equipment supplied. Following an initial review within the first six-month period. The maximum period between reviews will be one year. But within this time frame reviews on the use of particular pieces of equipment should be arranged wherever necessary. The decision on when to review in these circumstances should be made in consultation with the person using the equipment or their carer, by the care manager, their senior and the named person in each area team with a remit for monitoring technology. This practice guide will be under continuous review as new Assisted Living Technology is developed and experience in using the technology influences practice. If you wish to comment or make suggestions please contact the development section. 7
(APPENDIX 1) TECHNOLOGY ADVISERS AND THEIR ROLE AS PART OF AN INFRASTRUCTURE THAT SUPPORTS APPROPRIATE ACCESS TO ASSISTED LIVING TECHNOLOGY. It is proposed that there will be a pool of 12 technology advisers (2 per area team), one of which should be an O.T. These staff will be recruited from within the existing staff group and will be provided with an initial one-day training course followed by regular support sessions in order to keep them informed of new developments in this area. This core group of staff will also receive support and updates via group meetings with relevant staff from headquarters and the independent living section initially on a monthly basis, and thereafter at agreed regular intervals. This will provide an opportunity for them to share any practical difficulties encountered in the preceding month, to share good practice examples with their colleagues and to be kept informed of any changes in the range of equipment available. The role of the advisers is: To be able to provide their colleagues with up to date information on what Assisted Living Technology is available. To guide their colleagues through the legal and ethical issues that should be considered before supplying such technology. To offer advice on alternative practical solutions that may be appropriate. To advise colleagues on the process for requesting and monitoring equipment To liaise with other advisers and key staff members based at headquarters as to issues that arise with regard to the supply of Assisted Living Technology. The technology advisers will receive an initial training session that will encompass. A demonstration of the current range of equipment from two main suppliers. Some practical examples of the uses of Assisted Living Technology A broad insight into the legal and ethical issues that should be considered. An opportunity to design packages based on individual case studies Detail of the procedures to be followed by care managers, seniors social work staff, technicians and call centre operators at Merrystone care base and staff at the joint equipment store. ( See appendix 2) Other key players: Senior social work staff information sessions will be organised in each area team, just prior to the range of Assisted Living Technology becoming readily available. The call centre operators based at Merrystone. they will receive specific training on the programming of equipment and adjustments of programmes via the control centre. The technicians at the Joint Equipment Store- they will receive training on where to place specific pieces of equipment for maximum efficiency and how to programme equipment into receivers. 8
(APPENDIX 2) PROCEDURE: FOR ACCESSING ASSISTED LIVING TECHNOLOGY ASSESSORS CHECKLIST Accessing Assisted Living Technology. Assisted Living Technology may be considered for use in specific circumstances. The range of equipment available is purchased from different suppliers, but within North Lanarkshire council there are only two points of contact to order equipment from. The supply of Assisted Living Technology will be managed via the Joint Equipment Service. The Joint equipment service can supply a significant range of equipment that is particularly useful when there is no need for a response from the community alarm service. They can also supply and install a range of equipment that can be connected to community alarms. Merrystone Care Base can supply the community alarm. And arrange for a change of community alarm if an upgraded model is required. The technology advisers (see app 3) in each area team can offer practitioners advise as to the range of equipment available, how to place an order, the uses and limitations of this, and can assist care managers to establish whether or not Assisted Living Technology will be useful to an individual. Below is a checklist of steps, which should be followed before and after proceeding with the supply of any equipment. (fuller information about the process IS contained in the Department s PRINCIPLES AND GOOD PRACTICE GUIDANCE: USE OF ASSISSTIVE TECHNOLOGY (July 2003). 9
If following a full assessment of an individual and when all practical steps to minimise risk have been taken, it is considered that Assisted Living Technology may be useful in providing additional support to the person the following procedure should be undertaken. (see app 3&4) Contact the technology adviser in your area team Check that ethical, human rights and consent issues have been appropriately examined and recorded. Re-consider the scope for any alternative practical solutions. Seek approval from your Social Work Senior via recordings in care plan (D12) and then order via drop down boxes in Community Equipment section on SWIS.- (any equipment ordered must be deducted from shadow budgets). Place an order with the Joint equipment store. (Joint equipment store will fax copy to Merrystone.) Generally this technology is considered to be non- urgent, however there may be some exceptions to this which will be discussed at staff training. Advise joint equipment store and /or Merrystone of any details they will require in order to arrange delivery and installation. E.g. who should be there if the person has difficulty understanding what it is for. (You will be notified on delivery and installation of equipment). Consider any specific guidance that may be required for community alarm response staff and pass on details to Merrystone care base. Following notification of delivery and installation of equipment: - Notify any carers or home support staff of equipment once in place and check that they know how to use it. Adjust care plan to reflect changes in package. Monitor equipment for first four weeks in order to establish if it has been effective. Review regularly as agreed with senior staff and consider monitoring sheets from Merrystone care base as a basis for informing future or continuing use. Notify supplier when equipment is no longer required (Joint Equipment Service and/or Merrystone. 10
ASSESSMENT AND APPROPRIATE EQUIPMENT (APPENDIX 3) The range of Assisted Living Technology available is constantly changing. New suppliers are being identified with increasing regularity, and each can vary in their understanding of what the market requires. In order to design care packages that include Assisted Living Technology it is essential that care managers are not led by the supply of equipment, but instead focus on the needs identified in a full assessment of the individual and the environment they live in. They then need to consider the impact of these needs on the person s life and the response that is required in order to meet these needs. The following scenarios are designed to stimulate thinking on what the potential uses of some Assisted Living Technology in different situations. Some of the most common concerns of care managers are in realtion to safety needs. These are the risk of fires, falls, someone going out alone and gas alerts. Some of these have been discussed earlier in the paper. However it is perhaps worthwhile considering some alternative solutions that could have been designed. A door contact switch may be useful in alerting a responder when someone is going out, however in some situations it may be worth considering a passive infra red (PIR) monitor. This device if fitted strategically in the person s home and set to the times of high risk, may alert responders earlier and if a quick response can be provided may actually prevent an incident occurring. Similarly a pressure mat at the top of the stairs, or beside a bed can let someone know if someone is going down to the kitchen or hall and may put themselves at risk. If someone lives with a carer it may be appropriate that the equipment alerts the carer in the next bedroom, thereby ensuring that the person is supported in the assistance they require and that at other times the care can sleep undisturbed. A temperature extremes monitor in the kitchen may indicate that someone has left a door open and is at risk of hypothermia, or alert services that there is a fire. It could also provide the care manager with information on how cold the house is at key times and perhaps an oil filled radiator with a timer switch would reduce the risk of the person switching on a gas fire that they find difficult to ignite. If considering providing Assisted Living Technology that can compensate for disability many of these scenarios could have been prevented. E.g. by using a P.I.R. light with a built in message to remind the person not to switch on their cooker, to take keys or a coat with them if they are going out, or not to go out at all as it is dark are only some of the many ways these situations could be overcome. 11
(APPENDIX 4) ASSESSING THE REASON FOR FALLS Falls are a common problem for many older people, often with serious consequences in terms of morbidity and mortality. They can lead to fractures and sometimes require the person to be admitted to hospital. Sometimes falls are caused because the person is unwell, inner ear infections, dehydration, anaemia, low blood pressure and many other physical problems can often result in dizziness and falls. In order to rule out any of these possibilities a GP should be contacted in the first instance. However even with good medical assessments, many instances of recurrent falls remain undiagnosed and these people remain untreated and at risk of further falls. Some falls occur because houses are poorly maintained or because the person cannot see well. Here are some practical steps that can be taken to reduce the risk of falls in peoples own home. Loose rugs and carpets can be dangerous - check they have been secured. Check footwear is good fitting and in good condition. Make sure clothing is not too long and that there are no trailing belts. Make sure carers know to leave any walking aids near the person that they may need to walk safely. Try not to have flexes trailing across doorways when hoovering, keep moving the plugs to the nearest point instead. Carers should check the person is wearing clean glasses and maintain hearing aids if they cannot do this themselves. Hand rails or grab rails may need to be fitted in area where risks are high. Always have spare bulbs and fuses nearby. Automatic lighting may be worth considering. Try to ensure lights are working in darker corners, particularly if they are at a bend in the stairs. A night-light may be useful in some circumstances. A dimmer switch may be of use for some people. But people with dementia may misperceive their environment when lighting is low. This can cause increased agitation. Rubber tiles in patio s etc. may minimise incidence and impact in external areas. 12
Equipment To Better Manage Falls Falls are one of the greatest obstacles to independent living for many older people. Their early detection is an important step in providing people with the reassurance and confidence to maintain an active lifestyle. When someone lives with a carer or is in a care home it may be possible to find out when the person is up walking or when they are about to get up and may need support. Pressure mats *placed at the side of a bed or chair can let carers know when someone is up, and they in turn can check to see if the person is using walking aids or requires their assistance. Weight sensors or bed monitors* can alert a carer that someone is about to rise and they in turn can respond quickly and offer support. Infra red beams* can be placed at key points within the bedroom, and will alert a carer when there is movement in the room. When falls do occur it is important that assistance arrives as soon as possible. Wherever possible those who wear a call pendant should be encouraged to wear these at all times so they can summon help quickly. For some people with memory problems call pendants are less suitable and in these circumstances a fall detector may be more appropriate. 13
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